HIV in the U.S. Deep South

By Susan S. Reif, Center for Health Policy & Inequalities Research, Duke University and Carolyn McAllaster, Duke University School of Law and Elena Wilson, Duke University

April 12, 2017

Research

The Southern United States has been disproportionately affected by HIV, as this region has consistently experienced the highest HIV diagnosis rates and death rates of any US region. The Deep South region of the US South (defined herein as Alabama, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Texas) has borne a particularly high disease burden for HIV and is a significant driver of the U.S. HIV epidemic. We recently published an article in the Journal of Community Health documenting the higher HIV and AIDS diagnosis rates in the Deep South from 2008-2014 in comparison to other U.S. regions.

The Deep South also had the highest number of people diagnosed with HIV during this time period along with highest number of individuals living with HIV of any U.S. region. Additionally, deaths among individuals diagnosed with HIV are highest in the Deep South region. African Americans have been especially hard hit by HIV and represent a majority of new diagnoses as well as a majority of people living with HIV in the Deep South. New diagnoses among African American men who have sex with men continue to increase in the Deep South and the U.S. overall.

Despite the greater concentration of HIV in the U.S. Deep South, federal funding for HIV care (non-Medicaid and Medicare) and prevention continues to lag in the region, primarily due to lower levels of CDC funding per person living with HIV. Private funding for HIV is also less per capita in the Deep South. According to a study by Funders Concerned about AIDS, only 12% of private foundation funding for HIV in the U.S. was allocated to the Deep South in 2014 although 40% of those diagnosed with HIV in 2014 resided in the Deep South. In addition, all but one of the Deep South states have not expanded Medicaid, further limiting access to comprehensive health care among those not eligible for the Affordable Care Act or other private insurance options.

The majority of the Deep South States have prosecuted people living with HIV for actions like spitting or biting that pose negligible or no risk of HIV transmission.

The etiology of the Deep South epidemic is complex and multifaceted. Our article in the Journal of Community Health on HIV in the Deep South highlights recent research identifying contributing factors to the disproportionate HIV burden in the U.S. South and Deep South, including pervasive and multi-layered HIV-related stigma, poverty, high levels of sexually-transmitted infections, racial inequality and bias, barriers to medical and social services, and laws that further HIV-related stigma and fear. Laws that criminalize HIV-related sexual and other behaviors and prohibit syringe exchange are commonplace in the Deep South. The majority of the Deep South States have prosecuted people living with HIV for actions like spitting or biting that pose negligible or no risk of HIV transmission.

Our report recommends closing the gap in federal and private funding for HIV prevention and care, along with additional strategies to address the factors fueling the epidemic in the Deep South. These strategies include enhancing current HIV care and prevention models to better address social determinants of health and disseminating innovative interventions to reduce the significant impact of stigma on engagement in HIV prevention and care.

These strategies are consistent with recommendations in the National HIV/AIDS Strategy, which contains a goal for a 15% reduction in HIV diagnosis rate disparities in the South and outlined approaches to address HIV including allocating funding to be consistent with the geographic distribution of the epidemic, implementing holistic HIV care, and reducing HIV stigma and its negative consequences. Addressing the structural, financial, and cultural factors that contribute to the disproportionate Southern HIV epidemic will be critical to meeting the goals of the HIV/AIDS strategy and successfully abating the disease in the U.S.

Susan Reif, PhD, MS is a Research Scholar at the Center for Health Policy and Inequalities Research at Duke University with a doctoral degree in Health Policy and Administration. Dr. Reif leads the research team for the Southern HIV/AIDS Strategy Initiative research and advocacy partnership. She is also a principal investigator for a federally-funded project evaluating a comprehensive substance abuse treatment program for individuals living with HIV and has participated in the design, implementation, and analysis of a dozen other federally funded research projects that addressed HIV risk reduction and HIV care provision.

Carolyn McAllaster

Carolyn McAllaster, JD is a Clinical Professor of Law at Duke University School of Law and is the founder of the Duke AIDS Legal Project and the Duke HIV/AIDS Policy Clinic. She directs the Southern HIV/AIDS Strategy Initiative (“SASI”) and is a past co-chair of the North Carolina AIDS Action Network. Professor McAllaster teaches AIDS and the Law in addition to clinical law courses focusing on HIV/AIDS law and policy issues.

Elena Wilson

Elena Wilson, MPH is the project coordinator at Duke Center for Health Policy and Inequalities Research. She received her MPH at the University of North Carolina at Chapel Hill in health behavior and health education.